Approval Date: Pol: Proc:

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1 Page: 1 of 5 Pol: Policy It is the policy of Bay-Arenac Behavioral Health Authority (BABHA) to send a quarterly Performance Indicators (PI) Report to the Michigan Department of Community Health (MDCH) in a timely manner as indicated in the Medicaid Managed Specialty Services and Supports Contract. Purpose This policy and procedure is established to provide a clear and defined process for sending Medicaid (PIHP) Performance Indicator Reports to Mid-State Health Network and General Fund/Medicaid (CMHSP) Performance Indicator Reports to Michigan Department of Community Health. Education Applies to: All BABHA Staff Selected BABHA Staff, as follows: Management Staff and AAM Business Reporting Specialist All Contracted Providers: Policy Only Policy and Procedure Selected Contracted Providers, as follows: Policy Only Policy and Procedure BABHA s Affiliates: Policy Only Policy and Procedure Other: Definitions N/A

2 Page: 2 of 5 Pol: Procedure The MDCH PI Report delineates the dimensions of quality that are to be addressed by the public mental health system. The data is used to develop a statewide aggregate status report for the purposes of public accountability, contract management, and quality assurance. The data is also used to facilitate the development and implementation of performance improvement systems and initiatives internal to the Pre-Paid Inpatient Health Plan (PIHP) and/or Community Mental Health Services Program (CMHSP). The MDCH PI Report is produced and submitted four times annually and is due on the last day of the third month following each quarter. The first quarter covers October through December, the second covers January through March, the third covers April through June, and the fourth covers July through September. PI Reports are submitted to MDCH in the form of an MS Excel file that is electronically submitted via . Data Review Process: 1. BABHA, its contracted clinical service providers enter data into the electronic health record through clinical processes utilizing the calendar, appointment status, appropriate clinical documents, and service activity logs (SALS) from the electronic health record. Specific detailed instructions are located in the BABH PI Logic document referenced in the related forms. 2. Mid quarter, the PI Coordinator or designee runs the Performance Indicator Report (Reports and Downloads) in the Phoenix system This report identifies individuals who are eligible to be included in the (MMBPIS) report for each performance indicator. A list of individuals that are identified as outside of the standard or non-compliant and any anomalies, and omissions from being reported are reviewed by the PI Coordinator to ensure accuracy. If additional information needs to be obtained the records are then forwarded to the appropriate program for further review for accuracy and follow-up to ensure correction are made.

3 Page: 3 of 5 Pol: 4. Authorized staff from BABH and the clinical contracted service providers review their data and correct/revise as necessary in the correct location of the electronic health record. 5. Prior to the submission date, the PI Coordinator or designee will re-run the Performance Indicator Report (Reports and Downloads) in the Phoenix system. A final list of those individuals that are identified as outside of the standard or non-compliant with the indicator, anomalies and those that are omitted from being reported are reviewed by the PI Coordinator to ensure accuracy. If additional information needs to be obtained, the records are then forwarded to the appropriate program for further review if necessary. 6. Authorized staff from the BABH and the clinical contracted service providers review their data and correct/revise as necessary in the electronic health record. 7. Four (4) weeks prior to the submission date, the PI Coordinator will submit the PIHP (Medicaid only) MMBPIS Report to MSHN or MSHN Contract designee as required per MSHN policy. Corrective action will be completed in collaboration with the respective program and the PI Coordinator based on the performance of each indicator consistent with MSHN policy. 8. Two (2) weeks prior to the submission date, the PI Coordinator will provide BABH and its contracted clinical service providers a report which will include the CMHSP (all funding sources) MMBPIS Report to be submitted to MDCH. The report will include any need for corrective action based on the performance of each indicator by clinical service provider and program. Corrective action will be submitted to the PI Coordinator within 30 days of the report distribution date utilizing the Follow up to Data Analysis Form. The corrective action may be completed in collaboration with the PI Coordinator and the program.. 9. The template used for submission to the MDCH CMHSP Performance Indicator submission is located on the MDCH Website under the Reporting Requirements, Michigan s Mission-Based Performance Indicator System, Ver. 6.0 CMHSP Template. 10. The Performance Improvement Coordinator will provide additional detail data upon request.

4 Page: 4 of 5 Pol: The production of the MDCH MMBPIS report is a multi-step process using data from the Phoenix System and a review protocol of the Performance Improvement process. All MMBPIS eligibility criteria is performed within the Phoenix (PCE) system using specific source codes established and maintained by PCE. MMBPIS indicators and methodology are located in the MMBPIS PIHP and CMHSP Codebooks and can be found as related materials to this policy and procedure. Attachments MMBPIS BABH Project Description MMBPIS MSHN Project Description Related Forms Follow-up to Data Analysis Form Summary Report Form N/A

5 Page: 5 of 5 Pol: Related Materials MMBPIS PIHP Reporting Codebooks MMBPIS CMHSP Reporting Codebooks Bay-Arenac Behavioral Health PI Logic 5/12/2014 PCE-BABH Source Code References and/or Legal Authority MDCH Medicaid Managed Specialty Services and Supports Contract MMBPIS PIHP/CMHSP Reporting Codebooks Submission Form Approving Body/Committee/Supervisor: Janis Pinter Corporate Compliance Payor Committee Author/Reviewer: Marlene Wolber V. Rossman/M. Wolber Sandra Gettel Approval/Review Date: /25/ Result: Deletion New No Changes Replacement Revision List reason for deletion/replacement/revision here. If replacement, list policy to be replaced. Procedure revised to include BABH contract agencies now on PI database. Updated to reflect current practices. Implementation of electronic health record and reorganization of AAM/MSHN.